Use of a Chemotherapy Toxicity Prediction Tool to Decrease Risks for Hospitalization in Older Patients.

Objectives Performance status (PS) scales such as the Eastern Cooperative Oncology Group (ECOG) PS and the Karnofsky Performance Index have limited utility in selecting therapies and predicting related adverse events in older patients with cancer. In July 2016, medical oncologists at our institution adopted the Cancer and Aging Research Group toxicity prediction score (CARG), a toxicity prediction tool, to identify patients who are "fit" for chemotherapy versus those who are "frail" and may experience severe complications. Methods Our retrospective review included referrals of beneficiaries 75 years of age and older who received standard systemic therapy and patients of the same age whose treatment was modified due to CARG. We compared the score's utilization six months before and after its incorporation and then assessed how its application impacted admissions, emergency department (ED) visits, and medical management. Results Thirty-eight patients with a mean age of 81 years met the inclusion criteria. Their diagnoses included gastrointestinal (37%), lung (21%), hematologic (18%), breast (10.5%), genitourinary (3%), and other (10.5%) malignancies. CARG was documented for 12.5% of systemic therapy recipients before its adoption and 41% of recipients after adoption. Its use was limited by the reliance on physicians to perform scoring during time-constrained patient encounters. Patients had fewer mean inpatient admissions (0.7 versus 2.3), admission days (4.3 versus 8), and ED visits (1.1 versus 2.5) when management was modified based on the score. Conclusion CARG assessment may facilitate a safer and more tailored approach to cancer care in older patients than conventional PS scales alone. Its integration into patient screening would increase its application and better define its potential predictive capacity to decrease risks for hospitalization.

Healthcare related aversion and care seeking patterns of female aviators in the United States.

Diagnosis of a new medical condition in pilots may precipitate the end of an aviation career or hobby. For this reason, a barrier exists for pilots to seek medical care due to fear of losing an aeromedical certificate. Females represent a growing proportion of pilots in the United States and data on healthcare seeking behavior in this cohort is sparse. We conducted an anonymous online survey of 154 female pilots and 131 female non-pilots in the United States. 83.7% of female pilots have experienced healthcare related aversion compared to 27.5% of non-pilots. 66.7% of female pilots had withheld information from a physician while 46.0% had delayed or forwent medical care due to concern for their medical status. Further studies should be conducted to inform policy change to address pilot healthcare barriers.

Phlegmasia Cerulea Dolens: A Life-Threatening Manifestation of Deep Vein Thrombosis.

Deep vein thrombosis is a common condition encounter by hospitalists and managed by either oral or intravenous anti-coagulation. Although uncommon, phlegmasia cerulea dolens (PCD) is a life-threatening manifestation of acute deep vein thrombosis requiring early recognition and aggressive intervention to preserve life and limb. PCD is characterized by marked swelling of the lower extremities with pain and cyanosis, which often leads to gangrene and amputation. We present the case of a patient who developed PCD of her left lower extremity who was successfully treated with an EkoSonic™ endovascular catheter (Boston Scientific, Marlborough, MA, USA), which accelerates lytic dispersion of the thrombolytic drug through ultrasound technology.

Reducing the Inappropriate Use of Proton Pump Inhibitors in an Internal Medicine Residency Clinic.

Introduction Proton pump inhibitors (PPI) are commonly prescribed in the primary care setting. While generally considered to be safe, there is growing evidence suggesting that PPI misuse is associated with a variety of significant adverse outcomes and unnecessary cost. The goal of this quality improvement project was to identify patients with non-guideline recommended PPI prescriptions in our internal medicine residency clinics and implement a process to de-prescribe or reduce the dose of PPIs across this patient population. Methods PPI prescription rates, dosage, and indication were extracted from the medical records of all 854 patients empaneled to the internal medicine residency clinics at a multicenter closed referral military hospital system. Appropriate PPI indication was consensus based upon published guidelines, and patients without an appropriate indication were targeted for intervention. These patients were directly contacted by their primary care physicians, via phone or during a clinic visit, to discuss the risks and benefits of ongoing PPI use as well as alternative therapies or tapering regimens at the physician's discretion. For moderate to high dose PPI, the dose was decreased by 50% every week until the lowest tolerated dose was achieved or until discontinuation. For low dose PPI, discontinuation was recommended as the initial intervention. Six months following the intervention, the empanelment was reevaluated for ongoing PPI usage, tapered dosage, or discontinuation. Results Of a total of 854 patient records reviewed at the initiation of the project, 322 patients were noted to be prescribed PPIs. Of this subset, 66% (217/322) did not meet a guideline recommended indication for their use. At the completion of the six-month intervention period, 44% (96/217) of patients were successfully weaned to a reduced dose or were no longer using a PPI. Conclusions PPIs are widely used and generally considered to be a well-tolerated therapy for acid-secretion disorders. PPI overprescription and the associated adverse effects and economic burden are increasingly recognized. We show that a simple, focused, resident-driven quality improvement intervention can be effective in de-prescribing efforts to reduce inappropriate PPI use in the outpatient primary care setting.

Case report of penile Rhizopus arrhizus infection in an unexpected patient.

There are few reports of penile mucormycosis and even fewer in the absence of overt immune suppression. An eighty year old male with diabetes presents with penile mass. The pathology and culture demonstrated Rhizopus arrhizus. He was treated with surgery and liposomal amphotericin B. His therapy was stopped after pathology demonstrated clear surgical margins. His good outcome provides evidence that stopping antifungal therapy after achieving clear surgical margins is acceptable in patients without ongoing immunosuppression.

MLL1 and DOT1L cooperate with meningioma-1 to induce acute myeloid leukemia.

Meningioma-1 (MN1) overexpression is frequently observed in patients with acute myeloid leukemia (AML) and is predictive of poor prognosis. In murine models, forced expression of MN1 in hematopoietic progenitors induces an aggressive myeloid leukemia that is strictly dependent on a defined gene expression program in the cell of origin, which includes the homeobox genes Hoxa9 and Meis1 as key components. Here, we have shown that this program is controlled by two histone methyltransferases, MLL1 and DOT1L, as deletion of either Mll1 or Dot1l in MN1-expressing cells abrogated the cell of origin-derived gene expression program, including the expression of Hoxa cluster genes. In murine models, genetic inactivation of either Mll1 or Dot1l impaired MN1-mediated leukemogenesis. We determined that HOXA9 and MEIS1 are coexpressed with MN1 in a subset of clinical MN1hi leukemia, and human MN1hi/HOXA9hi leukemias were sensitive to pharmacologic inhibition of DOT1L. Together, these data point to DOT1L as a potential therapeutic target in MN1hi AML. In addition, our findings suggest that epigenetic modulation of the interplay between an oncogenic lesion and its cooperating developmental program has therapeutic potential in AML.